Annals of the Royal College of Surgeons of England (1990) vol. 72, 27-31
The efficiency of management of emergency surgery in a district general hospital a prospective study David J Flook MCh FRCS* Senior Surgical Registrar Michael K H Crumplin
MB BS FRCS
Consultant Surgeon
Wrexham Maelor Hospital, Wrexham
Key words: Emergency service, hospital; Efficiency
In a 6-month prospective study of management of surgical emergencies in a district general hospital, we have tried firstly to determine the degree to which non-life-threatening emergencies could be managed within 'social hours' (0800-1800), and secondly to identify examples of and reasons for potentially hazardous delay in the performance of urgent procedures. Emergency referrals undergoing surgery were categorised into three groups: Group A-patients requiring surgery either immediately or at the earliest possible time (maximum 3 h after diagnosis). Group B-patients requiring urgent but not immediate surgery (within 6 h of diagnosis). Group C-patients whose operations could be delayed until social hours without detriment. The reason for delay-shortage of theatre nursing, anaesthetic or surgical staff-was recorded in each case. Of the 95 patients in Group C (elective management) 63 (65%) underwent surgery within social hours, 15 (16%) between 1800 and 2100 and 17 (18%) at night. Unacceptable delays occurred in 37 (14%) of the 260 cases and were most likely to affect patients in Group A who most needed urgent care. We conclude that our current staffing levels in theatre nursing should be increased to consistently provide two (rather than one) staffed theatres for emergencies, in addition to a theatre team dedicated exclusively to obstetrics. Anaesthetic manpower should be increased to provide four duty anaesthetists with no more than one at SHO level as obstetric and intensive care duties can be complex. General surgical staffing requires expansion in order that on-call staff have no fixed commitments during and in the session immediately after their duty periods.
The recent Confidential Enquiry into Perioperative Deaths (1) (CEPOD) has suggested that 30% of the deaths in surgical practice were at least partly due to surgical failings and 7% of deaths were due entirely to surgical faults. Surgical failings resulted from a combination of inappropriate preoperative management, opera-
tive procedures and grade of operating surgeon. Errors in management were more frequent when junior surgeons acted without consultation or supervision by their seniors. It is generally accepted that a hospital which deals with surgical emergencies should keep one fully equipped operating theatre available at all times. It should thus be possible to perform the majority of urgent but not life-saving procedures during social hours, when senior surgical and anaesthetic staff are most readily available and at their freshest. It is equally important to emphasise that although a proportion of surgical emergencies can and often should be dealt with some hours or even days after admission, there remains a group of conditions for which surgery should be available within hours or even minutes of arrival. We thus set out to study prospectively over a 6-month period the efficiency of emergency surgical management in a district general hospital with two main aims in mind. Firstly, we hoped to determine the extent to which nonlife-threatening emergencies could be managed within social hours. Secondly, we wished to know whether there was delay in the management of urgent cases.
Methods Correspondence to: Mr M K H Crumplin, Consultant Surgeon, Wrexham Maelor Hospital, Croesnewydd Road, Wrexham, Clwyd LL13 7TD
The Maelor Hospital has 660 beds, providing for a local population of 228 000. It is staffed by four consultants in general surgery with one senior registrar, three regis-
28
D J Flook and M K H Crumplin
three senior house officers and four preregistration house officers. Currently, two teams of theatre nurses cover emergencies, with one of these dedicated solely to obstetrics. Anaesthetic cover for all surgical and obstetric emergencies and for the intensive care unit is usually provided by one consultant, one registrar and one senior house officer, with often a fourth anaesthetist on the intensive care unit during the day. All surgical staff were aware of the study being performed and at the outset and regularly during the 6-month period of the study, each was advised that our aim was to perform emergency surgery within social hours (locally defined as 0800-1800) unless this was likely to be to the detriment of the patient. Clinical conditions regarded as too urgent to be managed in this way were divided into two broad groups. First were conditions such as ruptured aortic aneurysm or arterial embolus, bleeding or perforated viscus, suspected mesenteric infarction or testicular torsion (Group A). These conditions were held to require surgery as soon as possible after diagnosis (unless resuscitation was needed before anaesthesia) and to permit a measure of delay, a maximum of 3 h was allowed between diagnosis and surgery. Included as a subdivision (Group A1) were patients with uncontrolled haemorrhage or major trauma who actually required immediate operation. Second were conditions such as appendicitis, incarcerated hernia and gastrointestinal bleeding requiring endoscopic assessment, and patients with intercurrent medical problems such as diabetes and cardiorespiratory disease which could deteriorate if acute inflammatory conditions were not expeditiously treated (Group B). For this group it was held that no more than 6 h should be allowed between diagnosis and reaching theatre. All other patients were felt to be suitable for elective management (Group C). Data concerning emergency surgical cases were obtained by establishing a separate register for all patients admitted as an emergency who subsequently underwent operation. The register was kept in the surgeons' changing room and was completed by the registrar or senior house officer responsible for each patient. In each case the patient's name, age, admission date and time, name and grade of surgeon and provisional and operative diagnosis were recorded. The time of operation was also noted and any delay calculated, either from the time of decision to operate in Groups A and B, or from the time for which surgery had been planned in all other cases. In all cases where there had been delay the recording officer attempted to define whether such delay had occurred due to shortage of theatre nurses or to unavailability of anaesthetic or surgical staff. In a similar fashion to previous studies (2,3) from this unit, night-time surgery was defined as that commencing between 2100 and 0800. trars,
register. Of these, 78 were major procedures, 90 intermediate and the remaining 92 minor procedures, the latter group including 40 upper alimentary endoscopies for gastrointestinal bleeding. Consultants performed 12 (4.6%) of the procedures (and assisted in a further six); 48 (18.4%) were carried out by the senior registrar (assisted in a further 10) and registrars and senior house officers performed 72 (27.6%) and 128 (49.4%) procedures, respectively. The timing of operations is shown in Table I. Most of the 48 patients who underwent surgery between 1800 and 2100 and some of the night cases had, in fact, been scheduled for operation during social hours. These were not classified as delayed cases unless the patient's management was compromised but 10 of these cases were performed by surgeons who were officially off duty. The remaining 94 (36.5%) operations were performed at night-4 (4% of night cases) by consultants, 11 (12%) by the senior registrar, 18 (19%) by registrars and 61 (65%) by SHOs. The distribution of cases among the four grades of surgeon is shown in Table II. Group A (patients requiring surgery within 3 h) included 47 patients (five in Subgroup Al), Group B (surgery within 6 h) 118 patients and 95 patients were felt to be suitable for elective management, Group C. Unacceptable delays occurred in 37 (14%) cases, none of whom were in Subgroup A1 (requiring immediate surgery). The incidence and duration of and reasons for delay in each of Groups A, B and C is shown in Tables III and IV. These patients had a mean age of 43 years, but their ages ranged from 2 months to 89 years. Three patients who suffered a delay were under 10 years of age and seven were over 70 years of age. Overall, only 63 (65%) of the 95 Group C patients had their operation during social hours, but 15 (15%) of the remainder underwent surgery between 1800 and 2100 and only 17 (18%) were inappropriately treated at night, either due to delay or poor planning. The incidence of delay and associated mortality in Group A patients is shown in Table V. There were no deaths in patients in Groups B and C. Within the 6-month period of the study, 21 separate days encompassed all of the 37 cases of delayed surgery, with up to four patients being affected on any day. There was no evidence that delays were most likely to occur on any particular day of the week.
Table I. Timing of operations Patient group A
Al
Results In the 6-month period January-July 1988, 260 emerentered on the emergency surgical
gency cases were
B
C Total
Social hours 0800-1800
Evening
Night
1800-2100
2100-0800
6
14 3 38 63
27 15
22 2 53 17
118
48
94
Management of emergency surgery in a district general hospital
29
Table I. Distribution of cases by grade of surgeons Procedure Gut perforation or bleeding Intestinal obstruction Appendicectomy Abscess + niinor inflammatory condition Complicated hernia and testicular torsion Aneurysm Endoscopy Miscellaneous
Consultant
Senior registrar
Registrar
4
8
16
7
3
11
8
4
1 0
3 7
10 6
66 26
0
3
9
13
0 11 2 Cholecystecomy 1 Ruptured diaphragm 1 Thyroidectomy/ tracheostomy 1 Embolectomy 48
1 21 1 Above-knee amputation
2 0 2 Embolectomies
12
Total
Discussion Management of less serious emergencies during social hours Of all emergency operations in this series, 45% were performed within social hours, which is encouraging. Nonetheless in Group C patients (suited to elective management), only 65% underwent operation between 0800 and 1800. The performance of some of the remaining 40% of Group C by surgeons in their off-duty time could be avoided by allowing on-call staff to deal with such cases, but such a policy would have considerable implications for continuity of patient care and would be considered undesirable by many surgeons. It should also be noted, however, that if our levels of 35% of Group C cases and 55% of emergency cases as a whole, continue to undergo evening or night-time surgery, the strain on senior surgeons will be greatly increased when junior manning is decreased as proposed in Achieving a Balance (4). It is clear that many operations are performed at night because all concerned are aware that it will not be possible to make suitable arrangements for surgery within social hours. This has the benefit for most patients of earlier operations, but as CEPOD (1) has shown, unsupervised junior staff occa-
Table III. Incidence and duration of delays
Group A Group B Group C
Total in group
Delays (%)
Duration in hours mean (range)
47 118 95
11 (24) 18 (15) 8 (8)
5 (2-14) 5 (3-8) 4.5 (2-8)
72
Senior house officer
0 7 1 Above-knee amputation 4 Embolectomies 128
sionally do perform inappropriate procedures, and this is far more likely to occur at night when supervision is more remote. A review of the cases in the present study suggested that a small number of patients might have been managed differently had they been treated by senior staff. One such example was a 92-year-old lady who underwent laparotomy for a sigmoid colon perforation even though she was clearly in ASA Class 5 preoperatively-a moribund patient who was not expected to survive 24 h with or without operation-as defined by the American Society of Anaesthetists (5). Surgical delays By reputation, National Health Service hospitals provide an efficient overall emergency service, but we know of no study which has attempted to audit the efficiency of provision of emergency surgery. In a recent review (3) of surgery in elderly patients in the Maelor Hospital, it was noted that only 41% of operations (both elective and emergency) were performed by senior surgeons (consultant or senior registrar). In the present study, a still lower proportion of cases (23%) were performed by seniors, largely (Table I) because of the high proportion of cases, such as appendicectomy and abscess drainage, which were considered within the expertise of more junior staff. Nonetheless, a proportion of the delays and cases of inappropriate timing of surgery in this study, might well have been avoided if there had been greater involvement of senior staff. There were unacceptable delays in the surgical management of 37 (14%) of 260 patients undergoing surgery after emergency referral in this review and delay was proportionately most frequent in Group A (24%), who were most in need of urgent surgery. None of the patients requiring immediate surgery (Subgroup Al)
30
D J Flook and M K H Crumplin
Table IV. Reasons for delay Shortage of one or more of the following
Group A Group B Group C All groups any involvement in delay*
Theatre nurses alone
Anaesthetist alone
2 8 2 26
1 3 4 15
Surgeon alone 1
Combinations 8 6 2
Total
11 18 8
10
* It will be noted that the figures in this column add up to more than 37. This is because on 16 occasions more than one element of the theatre staff/anaesthetist/surgeon triad were unavailable.
Table V. Incidence of delay and associated mortality in Group A Delay (deaths)
Condition
Subgroup A, Remainder Group A
Ruptured aortic aneurysm Uncontrolled GI bleeding I. Major trauma
2 (1) 1 (1) 2
Sl
( Perforated viscus J GI bleeding 1 Arterial embolus ? Testicular torsion
suffered a delay, but 11 of the 47 Group A subjects did, and four (36%) of these delayed patients died. Only two (5.5%) of the remaining 36 Group A patients died and both were in Subgroup Al, having surgery for uncontrolled haemorrhage-one a ruptured aortic aneurysm, the other a rebleed from a previously oversewn duodenal ulcer. While the numbers of these cases are too small to permit a valid statistical comparison, this is suggestive of a detrimental effect of delayed surgery. There were also cases in which delay seemed to have been at least partly responsible for subsequent problems; for example a 67-year-old lady taking steroids for arthritis who had suffered a mesenteric infarction. Surgery was delayed in this case by over 6 h and by the time of laparotomy there was an ileal perforation with generalised peritonitis. Small bowel resection and exteriorisation was performed and there was no further mesenteric infarction, but the patient eventually died after 6 days of overwhelming sepsis and renal failure. At the least, a delay in reaching theatre led to added discomfort, anxiety and inconvenience for the patients concerned. In addition, three of the delayed patients were less than 10 years old and seven were 70 years or older, and we feel that delays are particularly inappropriate in patients at the extremes of the age range. Most of the delays were due to shortage of only one of the theatre staff/anaesthetist/surgeon triad with lack of theatre nurses being the most frequent, followed closely by a shortage of anaesthetists (Table IV), but all three elements were deficient on several occasions. While significant unplanned delays were only recorded on 21 days over a 6-month period, an average of one or
No delay (deaths)
8 (4) 1 2
18 4 4 5
two patients are being inappropriately managed every week. This again shows that greater flexibility of staffing, or perhaps even an increase in manpower, is required in theatre nursing, anaesthesia and general surgery. We propose that a district general hospital such as ours should provide three full teams of theatre staff for emergencies. One team would cover obstetrics and the other two would cover general surgery, orthopaedics, gynaecology and the other disciplines. Suitable anaesthetic cover would comprise a consultant, a registrar and a further SHO or registrar plus a separate officer to cover the intensive care unit (in some hospitals this role might be occupied by a surgeon or a physician). Not only should there be a vacant emergency theatre but general surgical work programmes should be organised in such a way that the consultant, registrar or SHO on call could use the available emergency theatre to carry out emergency operations (whether from Group A, B or C) with senior supervision where appropriate. Thus, during an emergency intake day, the duty surgical staff should only be involved in work that can be relatively easily interrupted (eg ward rounds, administration or
teaching). This study has shown that the majority of surgical emergencies can be managed with acceptable efficiency in a district general hospital. A significant proportion, however, amounting to 14% (or one or two patients per week in this hospital) suffer a potentially detrimental delay in their management. It would appear that some of these delays are the inevitable consequence of inadequate levels of theatre nursing, anaesthetic and surgical staffing. It is also clear that the proposed changes in staffing
Management of emergency surgery in a district general hospital levels detailed in Achieving a Balance (4) will have to be accompanied by radically altered working practices, if surgeons are to be able to deal with emergency cases unhindered by a heavy load of routine work, during and immediately after their on-call periods.
2 3
The authors wish to thank Mr P S Anandaram, Mr N K Mihssen, Mr Z Zarifa, Mr G Griffiths, Dr K T Ong, Dr R Anwar and Mr A Sen for their help in running the study and Miss R Hall and Miss S Langford for secretarial assistance.
4
References
5
I Buck N, Devlin HB, Lunn JN. Report of the Confidential Enquiry into Perioperative Deaths. London: Nuffield
31
Provincial Hospitals Trust and The King Edward's Hospital Fund for London, 1987. Crumplin MKH et al. Management of gallstones in a district general hospital. BrJ7 Surg 1985;72:428-32. Barlow AP, Zarifa Z, Shillito RF, Crumplin MKH, Edwards E, McCarthy J. Surgery in a geriatric population. Ann R Coll Surg Engl 1989;71:110-114. Hospital Medical Staffing-Achieving a Balance-Plan for Action. Steering Group for Implementation on Behalf of the UK Health Departments, The Joint Consultants Committee and Chairman of Regional Health Authorities. Crown Copyright Oct 1987. Saklad M. Grading of patients for surgical procedures. Anesthesiology 1941;2:281-4.
Received 8 7une 1989
Notes on books Cancer Pain edited by Stephen E Abram. 173 pages, illustrated. Kluwer Academic Publishers, Boston. £45.75. Patients with advanced cancer should no longer endure pain but many do. Why should this be so? The answer is that inadequate treatment is too often administered and inadequate knowledge of the various methods of controlling pain now available is still widespread among physicians and nurses. This book explores the range of pain management techniques available today and should be read by all who care for patients with terminal malignant disease.
Orthopaedics and Fractures. A Question and Answer Study Guide by C Edmund Graham. 255 pages, illustrated, paperback. Butterworths, London. £9.95. A revision handbook comprising questions on the left-hand page and answers on the right. The text is complemented by over 100 radiographs. FRCS candidates please note.
Frontiers in Fracture Management edited by Timothy D Bunker, Christopher L Colton and John K Webb. 184 pages, illustrated. Martin Dunitz, London. 1989. £35.00. ISBN 0 948269 37 5 The three editors of this enterprising new book from the University Hospital, Nottingham have tried to ensure that the various chapters are scientific contributions to the orthopaedic aspects of trauma care. The first seven chapters are devoted to general fracture management, including the prevention of infection, skin cover, bone grafting and bone healing. One chapter stresses the importance of drawing detailed plans before embarking on the treatment of fractures. The second half of the book is devoted to specific orthopaedic topics such as the Herbert bone screw, functional bracing, proximal humeral fractures, interlocking medullary nailing and external fixation. Numerous clear line drawings and many black and white photographs complement the text.
A Guide to Practical Procedures in Medicine and Surgery by H A F Dudley, J R T Eckersley and S Paterson-Brown. 179 pages, illustrated, paperback. Heinemann Medical Books, Oxford. £12.50. Clear line diagrams and a simple concise text combine to make this an exceedingly useful handbook for house officers and medical students. How many readers of this notice knew exactly what to do when they first performed a pleural aspiration, a lumbar puncture or a suprapubic catheterisation? How many readers know now how to pass a nasogastric tube and then test that it is in the correct site? Why not buy this worthwhile book for use on your wards and find out?
Pulmonary Vascular Physiology and Pathophysiology edited by E K Weir and J T Reeves. 762 pages, illustrated. Marcel Dekker, New York. $150.00. Applying recent advances in molecular biology, this book presents important reviews of right ventricular function, highaltitude pulmonary oedema, the aetiologies of various forms of pulmonary hypertension as well as discussing such diverse areas as the lung in pregnancy, diving and exercise. Extensively referenced, the volume will prove an important reference work for anaesthetists as well as pulmonary physiologists.
Anatomical Exposures and Surgical Approaches to the Limbs by F Ruggieri, G F Zinghi, S Boriani and L Specchia. 291 pages, illustrated. Springer-Verlag, Vienna. DM298. A sumptuous atlas of surgical exposures in the upper and lower limbs. The full-page illustrations are particularly clear with sparing use of colour to highlight important structures. The text is printed in both English and German. This book would repay careful study, perhaps particularly by orthopaedic surgeons and vascular surgeons.
The efficiency of management of emergency surgery in a district general hospital a prospective study David J Flook MCh FRCS* Senior Surgical Registrar Michael K H Crumplin
MB BS FRCS
Consultant Surgeon
Wrexham Maelor Hospital, Wrexham
Key words: Emergency service, hospital; Efficiency
In a 6-month prospective study of management of surgical emergencies in a district general hospital, we have tried firstly to determine the degree to which non-life-threatening emergencies could be managed within 'social hours' (0800-1800), and secondly to identify examples of and reasons for potentially hazardous delay in the performance of urgent procedures. Emergency referrals undergoing surgery were categorised into three groups: Group A-patients requiring surgery either immediately or at the earliest possible time (maximum 3 h after diagnosis). Group B-patients requiring urgent but not immediate surgery (within 6 h of diagnosis). Group C-patients whose operations could be delayed until social hours without detriment. The reason for delay-shortage of theatre nursing, anaesthetic or surgical staff-was recorded in each case. Of the 95 patients in Group C (elective management) 63 (65%) underwent surgery within social hours, 15 (16%) between 1800 and 2100 and 17 (18%) at night. Unacceptable delays occurred in 37 (14%) of the 260 cases and were most likely to affect patients in Group A who most needed urgent care. We conclude that our current staffing levels in theatre nursing should be increased to consistently provide two (rather than one) staffed theatres for emergencies, in addition to a theatre team dedicated exclusively to obstetrics. Anaesthetic manpower should be increased to provide four duty anaesthetists with no more than one at SHO level as obstetric and intensive care duties can be complex. General surgical staffing requires expansion in order that on-call staff have no fixed commitments during and in the session immediately after their duty periods.
The recent Confidential Enquiry into Perioperative Deaths (1) (CEPOD) has suggested that 30% of the deaths in surgical practice were at least partly due to surgical failings and 7% of deaths were due entirely to surgical faults. Surgical failings resulted from a combination of inappropriate preoperative management, opera-
tive procedures and grade of operating surgeon. Errors in management were more frequent when junior surgeons acted without consultation or supervision by their seniors. It is generally accepted that a hospital which deals with surgical emergencies should keep one fully equipped operating theatre available at all times. It should thus be possible to perform the majority of urgent but not life-saving procedures during social hours, when senior surgical and anaesthetic staff are most readily available and at their freshest. It is equally important to emphasise that although a proportion of surgical emergencies can and often should be dealt with some hours or even days after admission, there remains a group of conditions for which surgery should be available within hours or even minutes of arrival. We thus set out to study prospectively over a 6-month period the efficiency of emergency surgical management in a district general hospital with two main aims in mind. Firstly, we hoped to determine the extent to which nonlife-threatening emergencies could be managed within social hours. Secondly, we wished to know whether there was delay in the management of urgent cases.
Methods Correspondence to: Mr M K H Crumplin, Consultant Surgeon, Wrexham Maelor Hospital, Croesnewydd Road, Wrexham, Clwyd LL13 7TD
The Maelor Hospital has 660 beds, providing for a local population of 228 000. It is staffed by four consultants in general surgery with one senior registrar, three regis-
28
D J Flook and M K H Crumplin
three senior house officers and four preregistration house officers. Currently, two teams of theatre nurses cover emergencies, with one of these dedicated solely to obstetrics. Anaesthetic cover for all surgical and obstetric emergencies and for the intensive care unit is usually provided by one consultant, one registrar and one senior house officer, with often a fourth anaesthetist on the intensive care unit during the day. All surgical staff were aware of the study being performed and at the outset and regularly during the 6-month period of the study, each was advised that our aim was to perform emergency surgery within social hours (locally defined as 0800-1800) unless this was likely to be to the detriment of the patient. Clinical conditions regarded as too urgent to be managed in this way were divided into two broad groups. First were conditions such as ruptured aortic aneurysm or arterial embolus, bleeding or perforated viscus, suspected mesenteric infarction or testicular torsion (Group A). These conditions were held to require surgery as soon as possible after diagnosis (unless resuscitation was needed before anaesthesia) and to permit a measure of delay, a maximum of 3 h was allowed between diagnosis and surgery. Included as a subdivision (Group A1) were patients with uncontrolled haemorrhage or major trauma who actually required immediate operation. Second were conditions such as appendicitis, incarcerated hernia and gastrointestinal bleeding requiring endoscopic assessment, and patients with intercurrent medical problems such as diabetes and cardiorespiratory disease which could deteriorate if acute inflammatory conditions were not expeditiously treated (Group B). For this group it was held that no more than 6 h should be allowed between diagnosis and reaching theatre. All other patients were felt to be suitable for elective management (Group C). Data concerning emergency surgical cases were obtained by establishing a separate register for all patients admitted as an emergency who subsequently underwent operation. The register was kept in the surgeons' changing room and was completed by the registrar or senior house officer responsible for each patient. In each case the patient's name, age, admission date and time, name and grade of surgeon and provisional and operative diagnosis were recorded. The time of operation was also noted and any delay calculated, either from the time of decision to operate in Groups A and B, or from the time for which surgery had been planned in all other cases. In all cases where there had been delay the recording officer attempted to define whether such delay had occurred due to shortage of theatre nurses or to unavailability of anaesthetic or surgical staff. In a similar fashion to previous studies (2,3) from this unit, night-time surgery was defined as that commencing between 2100 and 0800. trars,
register. Of these, 78 were major procedures, 90 intermediate and the remaining 92 minor procedures, the latter group including 40 upper alimentary endoscopies for gastrointestinal bleeding. Consultants performed 12 (4.6%) of the procedures (and assisted in a further six); 48 (18.4%) were carried out by the senior registrar (assisted in a further 10) and registrars and senior house officers performed 72 (27.6%) and 128 (49.4%) procedures, respectively. The timing of operations is shown in Table I. Most of the 48 patients who underwent surgery between 1800 and 2100 and some of the night cases had, in fact, been scheduled for operation during social hours. These were not classified as delayed cases unless the patient's management was compromised but 10 of these cases were performed by surgeons who were officially off duty. The remaining 94 (36.5%) operations were performed at night-4 (4% of night cases) by consultants, 11 (12%) by the senior registrar, 18 (19%) by registrars and 61 (65%) by SHOs. The distribution of cases among the four grades of surgeon is shown in Table II. Group A (patients requiring surgery within 3 h) included 47 patients (five in Subgroup Al), Group B (surgery within 6 h) 118 patients and 95 patients were felt to be suitable for elective management, Group C. Unacceptable delays occurred in 37 (14%) cases, none of whom were in Subgroup A1 (requiring immediate surgery). The incidence and duration of and reasons for delay in each of Groups A, B and C is shown in Tables III and IV. These patients had a mean age of 43 years, but their ages ranged from 2 months to 89 years. Three patients who suffered a delay were under 10 years of age and seven were over 70 years of age. Overall, only 63 (65%) of the 95 Group C patients had their operation during social hours, but 15 (15%) of the remainder underwent surgery between 1800 and 2100 and only 17 (18%) were inappropriately treated at night, either due to delay or poor planning. The incidence of delay and associated mortality in Group A patients is shown in Table V. There were no deaths in patients in Groups B and C. Within the 6-month period of the study, 21 separate days encompassed all of the 37 cases of delayed surgery, with up to four patients being affected on any day. There was no evidence that delays were most likely to occur on any particular day of the week.
Table I. Timing of operations Patient group A
Al
Results In the 6-month period January-July 1988, 260 emerentered on the emergency surgical
gency cases were
B
C Total
Social hours 0800-1800
Evening
Night
1800-2100
2100-0800
6
14 3 38 63
27 15
22 2 53 17
118
48
94
Management of emergency surgery in a district general hospital
29
Table I. Distribution of cases by grade of surgeons Procedure Gut perforation or bleeding Intestinal obstruction Appendicectomy Abscess + niinor inflammatory condition Complicated hernia and testicular torsion Aneurysm Endoscopy Miscellaneous
Consultant
Senior registrar
Registrar
4
8
16
7
3
11
8
4
1 0
3 7
10 6
66 26
0
3
9
13
0 11 2 Cholecystecomy 1 Ruptured diaphragm 1 Thyroidectomy/ tracheostomy 1 Embolectomy 48
1 21 1 Above-knee amputation
2 0 2 Embolectomies
12
Total
Discussion Management of less serious emergencies during social hours Of all emergency operations in this series, 45% were performed within social hours, which is encouraging. Nonetheless in Group C patients (suited to elective management), only 65% underwent operation between 0800 and 1800. The performance of some of the remaining 40% of Group C by surgeons in their off-duty time could be avoided by allowing on-call staff to deal with such cases, but such a policy would have considerable implications for continuity of patient care and would be considered undesirable by many surgeons. It should also be noted, however, that if our levels of 35% of Group C cases and 55% of emergency cases as a whole, continue to undergo evening or night-time surgery, the strain on senior surgeons will be greatly increased when junior manning is decreased as proposed in Achieving a Balance (4). It is clear that many operations are performed at night because all concerned are aware that it will not be possible to make suitable arrangements for surgery within social hours. This has the benefit for most patients of earlier operations, but as CEPOD (1) has shown, unsupervised junior staff occa-
Table III. Incidence and duration of delays
Group A Group B Group C
Total in group
Delays (%)
Duration in hours mean (range)
47 118 95
11 (24) 18 (15) 8 (8)
5 (2-14) 5 (3-8) 4.5 (2-8)
72
Senior house officer
0 7 1 Above-knee amputation 4 Embolectomies 128
sionally do perform inappropriate procedures, and this is far more likely to occur at night when supervision is more remote. A review of the cases in the present study suggested that a small number of patients might have been managed differently had they been treated by senior staff. One such example was a 92-year-old lady who underwent laparotomy for a sigmoid colon perforation even though she was clearly in ASA Class 5 preoperatively-a moribund patient who was not expected to survive 24 h with or without operation-as defined by the American Society of Anaesthetists (5). Surgical delays By reputation, National Health Service hospitals provide an efficient overall emergency service, but we know of no study which has attempted to audit the efficiency of provision of emergency surgery. In a recent review (3) of surgery in elderly patients in the Maelor Hospital, it was noted that only 41% of operations (both elective and emergency) were performed by senior surgeons (consultant or senior registrar). In the present study, a still lower proportion of cases (23%) were performed by seniors, largely (Table I) because of the high proportion of cases, such as appendicectomy and abscess drainage, which were considered within the expertise of more junior staff. Nonetheless, a proportion of the delays and cases of inappropriate timing of surgery in this study, might well have been avoided if there had been greater involvement of senior staff. There were unacceptable delays in the surgical management of 37 (14%) of 260 patients undergoing surgery after emergency referral in this review and delay was proportionately most frequent in Group A (24%), who were most in need of urgent surgery. None of the patients requiring immediate surgery (Subgroup Al)
30
D J Flook and M K H Crumplin
Table IV. Reasons for delay Shortage of one or more of the following
Group A Group B Group C All groups any involvement in delay*
Theatre nurses alone
Anaesthetist alone
2 8 2 26
1 3 4 15
Surgeon alone 1
Combinations 8 6 2
Total
11 18 8
10
* It will be noted that the figures in this column add up to more than 37. This is because on 16 occasions more than one element of the theatre staff/anaesthetist/surgeon triad were unavailable.
Table V. Incidence of delay and associated mortality in Group A Delay (deaths)
Condition
Subgroup A, Remainder Group A
Ruptured aortic aneurysm Uncontrolled GI bleeding I. Major trauma
2 (1) 1 (1) 2
Sl
( Perforated viscus J GI bleeding 1 Arterial embolus ? Testicular torsion
suffered a delay, but 11 of the 47 Group A subjects did, and four (36%) of these delayed patients died. Only two (5.5%) of the remaining 36 Group A patients died and both were in Subgroup Al, having surgery for uncontrolled haemorrhage-one a ruptured aortic aneurysm, the other a rebleed from a previously oversewn duodenal ulcer. While the numbers of these cases are too small to permit a valid statistical comparison, this is suggestive of a detrimental effect of delayed surgery. There were also cases in which delay seemed to have been at least partly responsible for subsequent problems; for example a 67-year-old lady taking steroids for arthritis who had suffered a mesenteric infarction. Surgery was delayed in this case by over 6 h and by the time of laparotomy there was an ileal perforation with generalised peritonitis. Small bowel resection and exteriorisation was performed and there was no further mesenteric infarction, but the patient eventually died after 6 days of overwhelming sepsis and renal failure. At the least, a delay in reaching theatre led to added discomfort, anxiety and inconvenience for the patients concerned. In addition, three of the delayed patients were less than 10 years old and seven were 70 years or older, and we feel that delays are particularly inappropriate in patients at the extremes of the age range. Most of the delays were due to shortage of only one of the theatre staff/anaesthetist/surgeon triad with lack of theatre nurses being the most frequent, followed closely by a shortage of anaesthetists (Table IV), but all three elements were deficient on several occasions. While significant unplanned delays were only recorded on 21 days over a 6-month period, an average of one or
No delay (deaths)
8 (4) 1 2
18 4 4 5
two patients are being inappropriately managed every week. This again shows that greater flexibility of staffing, or perhaps even an increase in manpower, is required in theatre nursing, anaesthesia and general surgery. We propose that a district general hospital such as ours should provide three full teams of theatre staff for emergencies. One team would cover obstetrics and the other two would cover general surgery, orthopaedics, gynaecology and the other disciplines. Suitable anaesthetic cover would comprise a consultant, a registrar and a further SHO or registrar plus a separate officer to cover the intensive care unit (in some hospitals this role might be occupied by a surgeon or a physician). Not only should there be a vacant emergency theatre but general surgical work programmes should be organised in such a way that the consultant, registrar or SHO on call could use the available emergency theatre to carry out emergency operations (whether from Group A, B or C) with senior supervision where appropriate. Thus, during an emergency intake day, the duty surgical staff should only be involved in work that can be relatively easily interrupted (eg ward rounds, administration or
teaching). This study has shown that the majority of surgical emergencies can be managed with acceptable efficiency in a district general hospital. A significant proportion, however, amounting to 14% (or one or two patients per week in this hospital) suffer a potentially detrimental delay in their management. It would appear that some of these delays are the inevitable consequence of inadequate levels of theatre nursing, anaesthetic and surgical staffing. It is also clear that the proposed changes in staffing
Management of emergency surgery in a district general hospital levels detailed in Achieving a Balance (4) will have to be accompanied by radically altered working practices, if surgeons are to be able to deal with emergency cases unhindered by a heavy load of routine work, during and immediately after their on-call periods.
2 3
The authors wish to thank Mr P S Anandaram, Mr N K Mihssen, Mr Z Zarifa, Mr G Griffiths, Dr K T Ong, Dr R Anwar and Mr A Sen for their help in running the study and Miss R Hall and Miss S Langford for secretarial assistance.
4
References
5
I Buck N, Devlin HB, Lunn JN. Report of the Confidential Enquiry into Perioperative Deaths. London: Nuffield
31
Provincial Hospitals Trust and The King Edward's Hospital Fund for London, 1987. Crumplin MKH et al. Management of gallstones in a district general hospital. BrJ7 Surg 1985;72:428-32. Barlow AP, Zarifa Z, Shillito RF, Crumplin MKH, Edwards E, McCarthy J. Surgery in a geriatric population. Ann R Coll Surg Engl 1989;71:110-114. Hospital Medical Staffing-Achieving a Balance-Plan for Action. Steering Group for Implementation on Behalf of the UK Health Departments, The Joint Consultants Committee and Chairman of Regional Health Authorities. Crown Copyright Oct 1987. Saklad M. Grading of patients for surgical procedures. Anesthesiology 1941;2:281-4.
Received 8 7une 1989
Notes on books Cancer Pain edited by Stephen E Abram. 173 pages, illustrated. Kluwer Academic Publishers, Boston. £45.75. Patients with advanced cancer should no longer endure pain but many do. Why should this be so? The answer is that inadequate treatment is too often administered and inadequate knowledge of the various methods of controlling pain now available is still widespread among physicians and nurses. This book explores the range of pain management techniques available today and should be read by all who care for patients with terminal malignant disease.
Orthopaedics and Fractures. A Question and Answer Study Guide by C Edmund Graham. 255 pages, illustrated, paperback. Butterworths, London. £9.95. A revision handbook comprising questions on the left-hand page and answers on the right. The text is complemented by over 100 radiographs. FRCS candidates please note.
Frontiers in Fracture Management edited by Timothy D Bunker, Christopher L Colton and John K Webb. 184 pages, illustrated. Martin Dunitz, London. 1989. £35.00. ISBN 0 948269 37 5 The three editors of this enterprising new book from the University Hospital, Nottingham have tried to ensure that the various chapters are scientific contributions to the orthopaedic aspects of trauma care. The first seven chapters are devoted to general fracture management, including the prevention of infection, skin cover, bone grafting and bone healing. One chapter stresses the importance of drawing detailed plans before embarking on the treatment of fractures. The second half of the book is devoted to specific orthopaedic topics such as the Herbert bone screw, functional bracing, proximal humeral fractures, interlocking medullary nailing and external fixation. Numerous clear line drawings and many black and white photographs complement the text.
A Guide to Practical Procedures in Medicine and Surgery by H A F Dudley, J R T Eckersley and S Paterson-Brown. 179 pages, illustrated, paperback. Heinemann Medical Books, Oxford. £12.50. Clear line diagrams and a simple concise text combine to make this an exceedingly useful handbook for house officers and medical students. How many readers of this notice knew exactly what to do when they first performed a pleural aspiration, a lumbar puncture or a suprapubic catheterisation? How many readers know now how to pass a nasogastric tube and then test that it is in the correct site? Why not buy this worthwhile book for use on your wards and find out?
Pulmonary Vascular Physiology and Pathophysiology edited by E K Weir and J T Reeves. 762 pages, illustrated. Marcel Dekker, New York. $150.00. Applying recent advances in molecular biology, this book presents important reviews of right ventricular function, highaltitude pulmonary oedema, the aetiologies of various forms of pulmonary hypertension as well as discussing such diverse areas as the lung in pregnancy, diving and exercise. Extensively referenced, the volume will prove an important reference work for anaesthetists as well as pulmonary physiologists.
Anatomical Exposures and Surgical Approaches to the Limbs by F Ruggieri, G F Zinghi, S Boriani and L Specchia. 291 pages, illustrated. Springer-Verlag, Vienna. DM298. A sumptuous atlas of surgical exposures in the upper and lower limbs. The full-page illustrations are particularly clear with sparing use of colour to highlight important structures. The text is printed in both English and German. This book would repay careful study, perhaps particularly by orthopaedic surgeons and vascular surgeons.
